Elective Labor Induction 2019 Update

Care Process Model MARCH 2019

ASSESSMENT FOR Elective Labor Induction 2019 Update

Labor induction involves the stimulation of uterine contractions to produce delivery before the onset of spontaneous labor. Induction of labor is indicated when the potential risks of continuing a pregnancy outweigh the benefits. At times, this is clear (e.g., when one of the indications listed on the following page threatens the health of the mother or baby). In other circumstances, the physician and patient may choose to induce labor to expedite delivery in the absence of well-accepted medical indications — that is to electively induce labor.HAR Common reasons for elective induction include a history of fast labors, patient living far from the hospital, advanced cervical dilation, and issues of convenience. As with any obstetrical procedure, the benefits of elective induction must be weighed against the potential maternal and fetal risks. The treatment guidelines summarized in this document were created by the Obstetrical Development Team of the Women and Newborns (W&N) Clinical Program at Intermountain Healthcare. The guidelines are derived from Intermountain practice outcomes, expert consensus, and recommendations from the American College of Obstetricians and Gynecologists (ACOG).ACO1

WHAT’S INSIDE? Why Focus on ELECTIVE LABOR INDUCTION? ALGORITHM...... 2 Since the initial adoption of the guidelines described in this care process Assessment of need for elective model (CPM), Intermountain has dramatically reduced the percentage of labor induction ...... 2 elective deliveries performed at < 39 weeks gestation — and not approved by Algorithm notes...... 3 Intermountain Maternal and Fetal Medicine (MFM) for special reasons — from 28 % of all elective deliveries in 1999, to less than 1 %. DATA & STATISTICS...... 4 Elective inductions that do not meet criteria recommended by ACOG (e.g., ≥ 39 REFERENCES...... 4 weeks gestation and Bishop score ≥ 8) may result in: • Increased risk for infection • Premature delivery MEASUREMENT • Longer labor due to the need for cervical ripening & GOALS • Scheduling and staffing challenges that both increase overall healthcare costs and inconvenience other practitioners and patients The primary goal of this CPM is to continue to educate physicians and patients on the safe and • Need for cesarean delivery (C-section) efficacious practice of elective labor induction. The primary measure will be tracking the However, recently published evidence concludes that elective labor induction at appropriate use of elective labor inductions. 39 weeks gestation as compared to expectant management, may be done safely GRO and result in the following: Indicates an Intermountain measure • No difference in perinatal morbidity • Decrease in the rate of C-section to 19 % in the induction of labor group as compared to 22 % in the expectant management group • Reduction of hypertensive disorders in the induction group to 9 % as compared to 14 % in the expectant management group • Better patient satisfaction in the induction of labor group (Note: See page 4 for more Intermountain and national data.)

ALGORITHM: ASSESSMENT OF NEED FOR ELECTIVE LABOR INDUCTION

Patient presents with potential need for elective labor induction

ESTABLISH gestational age (a)

no Is gestational age yes ≥ 39 weeks?

Elective labor induction NOT recommended ASSESS cervical ripeness (b)

Is Bishop score no > 8 in multigravida or yes > 10 in nulligravida? (b)

HOLD shared decision-making discussion with patient •• COUNSEL / EDUCATE patient (c) •• DISCUSS contraindications / precautions (d) •• OBTAIN patient consent

PREPARE for labor induction (e)

ALGORITHM NOTES

(a) Gestational age (c) Patient counseling Delivery, whether by induction or C-section, should be electively undertaken The patient should be counseled regarding: ACO1 ONLY AFTER: •• Indications for induction. •• 39 weeks gestation, regardless of fetal lung maturity testing •• Agents and methods of labor stimulation. •• Both the mother and fetus have been examined thoroughly (see note b) •• Possible need for repeat induction or C-section. •• The patient has given consent •• Intermountain patient education resources. The Intermountain fact sheet, In most patients, the gestational age is well-established by considering Elective Labor Induction — When is it okay?, is available in English and the menstrual dates based on last menstrual period (LMP) and obstetric Spanish at intermountain .net / pel or from Intermountain's Design & ultrasound findings. ACOG guidelines indicate that as soon as data from Print Center. the LMP, the first accurate ultrasound examination — or both — are obtained, the gestational age and the estimated date of delivery (EDD) should be determined, discussed with the patient, and documented clearly in the medical record (see ACOG’s Guidelines for Redating Based on Ultrasonography). ACO2 Assume fetal maturity (IF ANY): ACO1 •• Fetal heart tones have been documented for 20 weeks by non-electronic fetoscope or for 30 weeks by Doppler. •• It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test was performed by a reliable method. •• An ultrasound measurement of the crown-rump length, obtained at 6 – 12 (d) Contraindications and precautions weeks, supports a gestational age of ≥ 39 weeks. Contraindications Precautions •• An ultrasound scan, obtained at 13 – 20 weeks, confirms the The individual patient and clinical Several obstetric situations are gestational age (of ≥ 39 weeks) determined by clinical history and situation should be considered in not contraindications to labor physical examination. determining when labor induction is induction but do necessitate special (Note: Graphs on page 4 — generated with Intermountain data — show contraindicated. Contraindications precautions. These include, but are the increase in NICU admissions and ventilator usage in relation to include, but are not limited to, the not limited to, the following: ACO1 gestational weeks.) ACO1 following situations: •• One or more previous low- •• Vasa previa or complete transverse C-sections placenta previa •• Breech presentation (b) Assessment of cervical ripeness •• Transverse fetal lie •• Maternal heart disease The cervix should be assessed for its state of ripeness. It is recommended •• Umbilical cord prolapse •• Multifetal pregnancy that the physician or certified midwife use a Bishop score as part of •• Previous classical C-section •• Polyhydramnios the assessment process. (If needed, use a Bishop Score Calculator to •• Active genital herpes infection determine the score.) •• Presenting part above the pelvic inlet •• Previous myomectomy entering •• Severe hypertension Ideally, the Bishop score should be > 8 in multigravida women and > 10 in the endometrial cavity nulligravida women. If the Bishop score is > 8, the probability of vaginal •• Abnormal fetal heart rate patterns delivery after induction is similar to that of spontaneous labor.ACO1 not necessitating emergent delivery Longer labor and delivery, and unplanned C-sections, result in more complications for mother and baby and always add cost. (Note: Graphs on page 4 — generated with Intermountain data — show (e) Preparation for induced labor how the Bishop score relates to rates of unplanned C-sections and to The following records / personnel should be present and available: average hours in labor and delivery for nulligravida elective inductions.) •• The patient’s prenatal record should be on the patient’s chart. •• Personnel familiar with the maternal and fetal effects of uterine- stimulating agents should be in attendance during labor induction. •• A physician who has privileges to perform C-sections.

REFERENCES DATA & STATISTICS NICU Admissions By Weeks Gestation Deliveries Without Complications 2000-2006 ACO1SIDE ACOGBAR Committee HEAD 1on Practice 10% Side barBulletins main body — Obstetrics. text with ACOG emphasis Practice . Intermountain Healthcare Bulletin No. 107: Induction of labor. 8% t

Labor induction at < 39 weeks gestation: Intermountainen data show that deliveries Obstet Gynecol. 2009;114(2 Part 1): 6% Side bar head 2 rc

386-397. Pe Side bar main body text. at < 39 weeks gestation result in an increased number of neonates with NICU admits ACO2 ACOG Committee Opinion No. 611: (see figure 1a), respiratory distress syndrome, and4% ventilator usage (figure 1b), thereby • SideMethod bar lead-in for estimating . Side bar due bullet date. 1.Obstet increasing neonatal morbidity in such infants. 2% Side Gynecol.bar bullet 2014;124(4):863-866. 1 with indent. 8.85% 4.51% 3.34%3.62% 4.44%4.96% 0% CDC1–– Side Martin bar bulletJA, Hamilton 2. BE, Sutton PD, et 37th Week 38th Week 39th Week 40th Week 41st Week 42nd Week FIGURE 1a FIGUREn=16,73 71b n=37,064 n=65,756 n=34,179 n=7,858 n=343 Gestational Weeks ––al.Side Births: bar bulletFinal data3. for 2006. Natl Vital Stat Rep. 2011:57(7):1-101. NICU Admissions By Weeks Gestation Ventilator Usage By Weeks Gestation 1. Side bar numbered list. Deliveries Without Complications 2000-2006 Deliveries Without Complications 2000-2006 CDC2 Martin JA, Hamilton BE, Ventura MA, et 10% 2.00%

2. Sideal. bar Births: numbered Final data list. for 2009. Natl Vital 1.75% Stat Rep. 2011:60(1):1-71. 8% Sidebar check boxes 1.50% t 1.25% en CDC3 Martin JA, Hamilton BE, Osterman 6% Side bar emphasis . Sidebar italics text. rc t MJK, Curtin SC, Matthews TJ. Births: Pe 1.00% en rc 4% 0.75% Final data for 2012. Natl Vital Stat Rep. Pe

2013:62(9):1-71. 0.50%

2% CDC4 Martin JA, Hamilton BE, Osterman 0.25% 1.39% 0.49% 0.28% 0.32% 0.46% 0.87% 8.85% 4.51% 3.34%3.62% 4.44%4.96% 0.00% MJK, Driscoll AK, Drake P. Births: Final 0% 37th Week 38th Week 39th Week 40th Week 41st Week 42nd Week 37th Week 38th Week 39th Week 40th Week 41st Week 42nd Week n=16,737 n=37,064 n=65,756 n=34,179 n=7,858 n=343 data60% for 2017. Natl Vital Stat Rep. n=16,737 n=37,064 n=65,756 n=34,179 n=7,858 n=343 Cesarean SectionGestational Rates By Weeks Bishop Score Gestational Weeks 2018:67(8):1-50% 49. Elective Inductions in First-Time Moms 2001-2006 60% Ventilator Usage By Weeks Gestation 40% 37.5% 51.4% Deliveries Without Complications 2000-2006 CLA Clark SL, Miller DD, Belfort MA, Dildy 50% 2.00% GA,30% Frye DK, Meyers JA. Neonatal and 40% 37.5% Unfavorable1.75% Bishop score (< 8 in multigravida; < 10 in nulligravida):

Percent C-Sections 35.4% maternal20% outcomes associated with 33.6%

30% elective term delivery. Am J Obstet Intermountain1.50% 26.3%data show that patients who have an elective labor induction with an 10%

1.20%25% Gynecol. 2009;200(2):156.e1-156.e4. unfavorable Bishop17.6% score16.5% 17.2% spend more time in labor and delivery (figure 2a) and are Percent C-Sections 0% 13.3% 13.4%

Zero One t 1.00% 10% 8.1% GRO Grobman WA, Rice MM, Reddy UM, et moreen likely to need an unplanned5.8% C-section (figure 2b). rc 1.8% 0.75% 0.0% al. Labor induction versus expectant Pe 0% Zero OneTwo ThreeFour Five SixSeven Eight Nine TenElevenTwelveThirteen n=15 n=35 n=65 n=122 n=243 n=408n=648 n=894 n=1138 n=1081 n=1422 n=587 n=56 n=7 management in low-risk nulliparous 0.50% FIGURE 2a Bishop Score FIGURE 2b 0.25% women. N Engl J Med. 2018;379(6): 60%

1.Av39% erage Hours0.49% in Labor0.28% & Deli0.ve32% ry By Bishop0.46% Scor0.e87 % Cesarean Section Rates By Bishop Score 513-523. 0.00% Elective Inductions in First-Time Moms 2001-2006 5037%th Week 38Electiveth Week Inductions39th Wein ekFirst-Time 40 Momsth Week 2001-200 416st Week 42nd Week n=16,737 n=37,064 n=65,756 n=34,179 n=7,858 n=343 25 60%

HAR Harris S, Buchinski B, Grzybowski S, 40% Gestational Weeks 37.522.02% 51.4%

y 50% 19.70 19.99 Janssen P, Mitchell GW, Farquharson D. 20 30% 17.63 16.56 Induction of labour: A continuous quality 40% 37.5% 15.20

Percent C-Sections 35.4% 15 33.6% 20% 13.77 improvement and peer review program 12.47 30% 11.44 26.3% 10.45 to improve the quality of care. Can Med 10 10% 9.56 8.76 20% 7.40 17.6% 16.5% 17.2%

Assoc J. 2000;163(9):1163-1166. 6.27 Percent C-Sections 0% 13.3% 13.4% Zero One 5 10% 8.1%

Hours in Labor and Deliver 5.8% OSH Oshiro BT, Henry E, Wilson J, Branch 1.8% 0.0% 0 0% Zero OneTwo ThreeFourFiveSix SevenEight Nine TenElevenTwelveThirteen Zero OneTwo ThreeFour Five SixSeven Eight Nine TenElevenTwelveThirteen DW, Varner MW; Women and n=15 n=35 n=65 n=122 n=243 n=408n=648 n=894n=1138n=1081n=1422n=587 n=56 n=7 n=15 n=35 n=65 n=122 n=243 n=408n=648 n=894 n=1138 n=1081 n=1422 n=587 n=56 n=7 Newborn Clinical Integration Program. Bishop Score Bishop Score Decreasing elective deliveries before Average Hours in Labor & Delivery By Bishop Score 39 weeks of gestation in an integrated Elective Inductions in First-Time Moms 2001-2006 health care system. Obstet Gynecol. 25 United States 22.02 y 19.70 19.99 2009;113(4):804-811. 20 17.63 16.56 The overall rate of labor induction in the U.S. more than doubled15.20 during a 20-year 15 13.77 CDC1, CDC2 12.47 11.44 period, from 9.6 % in 1990 to 23.2 % in 2009. While the rate decreased10.45 10 9.56 8.76 7.40 slightly to 22.8 % in 2012, it steadily increased each of the following years, reaching6.27 CDC3, CDC4 5 CPM DEVELOPMENT TEAM 25.7 % in 2017. Elective labor inductionsHours in Labor and Deliver without a clear medical or obstetric

0 OSH,Zero CLAOneTwo ThreeFourFiveSix SevenEight Nine TenElevenTwelveThirteen indication have also been increasingly common. n=15 n=35 n=65 n=122 n=243 n=408n=648 n=894n=1138n=1081n=1422n=587 n=56 n=7 David Jackson, MPH (Medical Writer) Bishop Score Jean Millar, MBA, RN Kristi Nelson, MBA, RN Dina Olsen, MSN, RN This CPM presents a model of best care based on the best available scientific evidence at the time Donna Dizon-Townson, MD of publication. It is not a prescription for every physician or every patient, nor does it replace clinical judgment. All statements, protocols, and recommendations herein are viewed as transitory and iterative. Although physicians are encouraged to follow the CPM to help focus on and measure quality, deviations are a means for discovering improvements in patient care and expanding the knowledge base. Send feedback to Jean Millar, Intermountain Healthcare, Clinical Operations Director ([email protected]).